CC EXAM 2 EAQ
Which integumentary changes can be anticipated in a pt w/ a platelet count of 60,000? SATA a) Cyanosis b) Petechiae c) Varicosity d) Ecchymosis e) Hematoma
b) Petechiae d) Ecchymosis e) Hematoma
Which change in the pt lab values indicates the pt is in septic shock? a) Blood glucose: 80 b) Increased serum lactate c) Increased neutrophils d) WBC: 5,000
b) Increased serum lactate
The nurse is caring for a pt w/ a pneumothorax & a chest tube. Which assessment finding indicates that the chest tube has been effective? a) Productive coughing b) Return of breath sounds c) Increased Pleural drainage in the chamber d) Constant bubbling in the water-seal chamber
b) Return of breath sounds
Which nursing action has the highest PRIORITY for a pt w/ delirium? a) Maintaining skin integrity b) Planning for behavioral interventions c) Creating a calm & safe environment d) Maintain personal contact through touch
c) Creating a calm & safe environment
A pt is en route to the ED after sustaining a gunshot wound to the chest. Which PRIORITY nursing action would the nurse take to prepare for the arrival of the pt? a) Reserve an OR b) Organize equipment for tracheostomy c) Prep equipment for chest tube insertion d) Arrange for a portable chest x-ray examination
c) Prep equipment for chest tube insertion
A pt develops subcutaneous emphysema after the surgical creation of a tracheostomy. Which assessment by the nurse most readily detects this complication? a) Palpating the neck & face b) Evaluating ABGs c) Auscultating lungs d) Reviewing the chest x-ray
a) Palpating the neck & face
Which type of support provides immediate relief to the pt w/ tongue occlusion, loss of gag reflex, alterations in LOC, O2 sat: 40 & CO2: 75? a) Tracheostomy b) Laryngeal repair c) Abdominal thrust maneuver d) Autotitrating positive airway pressure
a) Tracheostomy
Which intervention would the nurse implement for a pt who is confused & delirious? a) Reassuring the pt that it will get better b) Directing the pts daily activities on the unit c) Helping the pt gain insight into personal behavior d) providing the pt w/ solutions to past & current problems
b) Directing the pts daily activities on the unit
Which characteristic mental change occurs w/ delirium & differentiates it from dementia? SATA a) Daytime sleepiness b) Rapid onset confusion c) Lasts over several years d) Progressive deterioration e) Apathetic thought process
b) Rapid onset confusion
When caring for a pt who has a hemo-pneumothorax & a chest tube, which prescribed acton by the HCP would the nurse question? a) Autotransfuse the blood in the collection chamber after 6 hrs b) Disconnect the drainage system from suction to ambulate the pt c) Add sterile water to the suction control chamber to maintain 20 cm suction d) Use a dressing impregnated w/ petroleum jelly around the insertion site
a) Autotransfuse the blood in the collection chamber after 6 hrs
Which early signs of respiratory acidosis would the nurse expect the pt w/ restrictive airway disease exhibit? SATA a) Headache b) Irritability c) Restlessness d) Hypertension e) Lightheadedness
a) Headache b) Irritability c) Restlessness
When ABGs result for an alert pt who is in the PACU after abdominal surgery are pH: 7.37, PaCO2: 42, HCO3: 25, PaO2: 65, SaO2: 90%, which action would the nurse take? a) Increase the O2 flow rate b) Insert an oropharyngeal airway c) Suction the oropharynx & upper trachea d) Prepare to transfer the pt out of the PACU
a) Increase the O2 flow rate
For which condition is fresh frozen plasma (FFP) ordered? a) Thrombocytopenia b) O2 deficiency c) Clotting factor deficiency d) Low hemoglobin
c) Clotting factor deficiency
A pt w/ severe hyperkalemia develops acidosis. Immediate administration of which medication can help prevent a life-threatening crisis? a) 50% Dextrose b) Furosemide c) Sodium Bicarbonate d) Epinephrine
c) Sodium Bicarbonate
When caring for a sedated pt who is being mechanically ventilated, which action will the nurse take FIRST when the low flow alarm is persistently sounding? a) Adjust the alarm settings b) Notify the RT c) Ventilate manually & call for assistance d) Check all connections & ventilator tubing
c) Ventilate manually & call for assistance
After insertion of a central venous catheter through the left subclavian vein, a pt reports chest pain & dyspnea w/ decreased breath sounds on the left side. Which actions would the nurse take FIRST? a) Administer O2 as prescribed b) Activate the rapid response team c) Give the prescribed PRN morphine sulfate d) Assist the pt to cough & deep breathe
a) Administer O2 as prescribed
After surgery, a pt is extubated n PACU. Which clinical manifestation would the nurse expect if the pt is experiencing ARDS? SATA a) Confusion b) Hypocapnia c) Tachycardia d) Constricted pupils e) Slow respiratory rate
a) Confusion b) Hypocapnia c) Tachycardia
When performing a focused respiratory assessment, which action would the nurse take FIRST? a) Examine for any abnormal respiratory patterns b) Inspect for changes in skin color or temperature c) Check for evidence of respiratory distress d) Determine shape & symmetry of chest
c) Check for evidence of respiratory distress
The nurse is caring for a pt whose mechanical ventilator settings include the use of PEEP. This treatment improves oxygenation primarily through which mechanism of action? a) Providing more O2 to lung tissue b) Forcing pressure into lung tissue, which improves gas exchange c) Opening collapsed alveoli & keeping them open d) Opening collapsed bronchioles, which allows more O2 to reach the lung tissue
c) Opening collapsed alveoli & keeping them open
Which action would the nurse take to decrease a pts risk for sensory & cognitive disturbances after a CABG surgery? a) Restrict family visiting times to a few hours daily b) Withhold analgesic medications during the day c) Plan to minimize interruption of sleep at night d) Place the pt in a room near the nurses station
c) Plan to minimize interruption of sleep at night
A pt w/ an AKI has peritoneal dialysis prescribed & asks why the procedure is necessary. Which response would the nurse use? a) "PD prevents the development of serious heart problems by removing damaged tissues" b) "PD helps perform some of the work usually performed by the kidneys" c) "PD stabilizes the kidney damage & may restart your kidneys to perform better than before" d) "PD speeds up recovery bc the kidneys are not responding to regulating hormones"
b) "PD helps perform some of the work usually performed by the kidneys"
Which action would the nurse take when caring for a pt w/ a pneumothorax who has a chest tube & closed drainage system in place? a) Avoid adding any additional water to the suction control chamber b) Check the water-seal chamber for evidence of bubbling during expiration c) Milk the chest tube periodically to prevent clots from obstructing the tube d) Call the HCP if there is bubbling in the suction control chamber
b) Check the water-seal chamber for evidence of bubbling during expiration
Which action would the nurse take to decrease risk of ventilator-associated-pneumonia (VAP) in a pt who is receiving mechanical ventilation? a) Suction the pt on a regular schedule b) Elevate HOB at least 30* c) Schedule daily changes of the ventilator tubing d) Maintain continuous sedation during ventilator use
b) Elevate HOB at least 30*
A pt develops bacterial pneumonia & is admitted to the ED. The pt initial PaO2: 80. When the ABGs are drawn again the PaO2: 65. Which action would the nurse take FIRST? a) Ensure intubation equipment available b) Increase O2 flow rate per facility protocol c) Notify HCP to request chest x-ray d) Recheck the ABG to verify accuracy
b) Increase O2 flow rate per facility protocol
Which action would the nurse anticipate implementing when caring for a pt w/ ARDS who is intubated & on mechanical ventilation? a) Deflate the ETT cuff hourly b) Schedule change in ventilator tubing every 24 hrs c) Determine need for suctioning based on pt assessment d) Leave FiO2 at the highest setting as the pt oxygenation improves
c) Determine need for suctioning based on pt assessment
Which finding best indicates that the chest tube for a pt w/ a pneumothorax may be discontinued? a) Clear breath sounds heard in both lungs b) O2 saturation reading > 90% c) Absence of bubbling in the water-seal chamber d) Full re-expansion of the lungs on chest x-ray
d) Full re-expansion of the lungs on chest x-ray
A pt w/ spontaneous pneumothorax asks, "Why did they put this tube in my chest?" Which information would the nurse provide about the purpose of the chest tube? a) It checks for bleeding in the lung b) It monitors the function of the lung c) It drains fluid from the pleural space d) It removes air from the pleural space
d) It removes air from the pleural space
When a norepinephrine IV infusion is prescribed for a pt in septic shock, which IV line would the nurse choose? a) Implanted port b) Midline catheter c) 18-guage peripheral venous catheter d) Peripherally inserted central catheter (PICC) line
d) Peripherally inserted central catheter (PICC) line
The nurse is caring for a pt w/ a history of COPD who develops a pneumothorax & has a chest tube inserted. Which primary purpose of the chest tube will the nurse consider when planning care? a) Lessens the pts chest discomfort b) Restores the negative pressure in the pleural space c) Drains accumulated fluid from the pleural cavity d) Prevents subcutaneous emphysema in the chest wall
b) Restores the negative pressure in the pleural space
Which information would the nurse include in response to a pt questioning a protein restricted dietary change required for their AKI? a) "A high-protein intake ensures an adequate daily supply of amino acids to compensate for losses" b) "Essential & nonessential amino acids are necessary in the diet to supply materials for tissue protein synthesis" c) "This diet supplies only essential amino acids, reducing the amount of metabolic waste products, thus decreasing stress on the kidneys" d) "Currently, your body is unable to synthesize amino acids, so the nitrogen for amino acid synthesis must come from the dietary protein"
c) "This diet supplies only essential amino acids, reducing the amount of metabolic waste products, thus decreasing stress on the kidneys"
When the chest x-ray for a pt who has arrived at the ED w/ chest trauma shows multiple rip fractured ribs which action will the nurse take next? a) Administer the prescribed morphine sulfate b) Assist the pt to take deep breaths & cough c) Check for paradoxical movement of the chest wall d) Teach the pt about ways to manage rib pain
c) Check for paradoxical movement of the chest wall
A pt had a wedge-resection of a lobe of the lung & now has a chest tube w/ a 3 chamber underwater drainage system in place. The nurse recalls that the 3rd chamber has which purpose? a) Acts as a drainage container b) Provides airtight water seal c) Controls the amount of suction d) Allows for escape of air bubbles
c) Controls the amount of suction
The nurse is caring for a diabetic pt w/ a bacterial infection of the foot, which assessment finding indicates a need to activate the rapid response team? a) Hypertonic bowel sounds in all 4 quadrants b) Blood glucose 145 c) Pt report of level 9 pain in the foot d) Systolic BP persistently 85-90
d) Systolic BP persistently 85-90
In which order would the pt w/ these conditions received prioritized care? a) Cystitis b) Chest pain from ischemia c) Penetrating chest trauma d) Minor burns e) Hip fracture
1 - c) Penetrating chest trauma 2 - b) Chest pain from ischemia 3 - e) Hip fracture 4 - a) Cystitis 5 - d) Minor burns
Which task can be delegated safely by the RN to the unlicensed nursing personnel for a pt w/ thrombocytopenia? a) Shaving the pt b) Positioning the pt c) Maintaining oral hygiene d) Giving IV platelet infusions
b) Positioning the pt
Which nursing interventions would be appropriate for a pt who suffocated due to smoke inhalation during a fire who have absent breath sounds? SATA a) Using the jaw-thrust maneuver b) Preparing for intubation c) Removing or suctioning any foreign bodies d) Preparing for needle thoracostomy & chest tube insertion e) Inserting OG or NG airway, ETT & cricothyroidotomy
b) Preparing for intubation d) Preparing for needle thoracostomy & chest tube insertion
Which is the function of the water-seal chamber on a closed chest drainage system for a pt w/ a hemothorax? a) Collects drainage from the pleural space b) Prevents reflux of air back into the pleural space c) Promotes drainage of blood from pleural space d) Controls level of suction applied to intrapleural space
b) Prevents reflux of air back into the pleural space
The nurse is caring for a pt w/ an ETT. Which is the most effective way for the nurse to loosen the respiratory secretions? a) Increase Oral fluid intake b) Provide chest physiotherapy c) Humidify the O2 d) Instill a saturated solution of potassium iodine
c) Humidify the O2
Which collaborative action would the nurse anticipate when caring for a pt w/ pneumonia whose ABGs are pH: 7.24, PaCO2: 60, HCO3: 20, PaO: 54, O2 sat: 88%? a) O2 at 6L/min NC b) Nebulized albuterol treatment c) Intubation & mechanical ventilation d) Sodium Bicarb IV
c) Intubation & mechanical ventilation
Which condition of the pt w/ laryngeal trauma & hemoptysis stands 1st in PRIORITY? a) Dyspnea b) Aphonia c) Hoarseness d) Subcutaneous emphysema
a) Dyspnea
Which information would the nurse educator include in a presentation on how to care for pts w/ chest tube drainage system? SATA a) Ensure chest tube dressing is tight & intact b) Palpate the skin to detect subcutaneous emphysema c) Place the chest tube drainage system below the chest d) Quickly attempt to reinsert the chest tube if it falls out e) Strip the chest tube w/ long strokes to promote drainage
a) Ensure chest tube dressing is tight & intact b) Palpate the skin to detect subcutaneous emphysema c) Place the chest tube drainage system below the chest
A pt experiences a lateral crushing chest injury. Assessment findings include obvious right-sided paradoxical motion of the chest & multiple rib fractures, resulting in a flail chest. The nurse would monitor the pt for which complication? a) Mediastinal shift b) Tracheal laceration c) Open pneumothorax d) Pericardial tamponade
a) Mediastinal shift
A pt has a platelet count of 49,000. The nurse would instruct the pt to avoid which activity? a) Ambulation b) Blowing the nose c) Visiting w/ children d) Eating fresh fruits & veggies
b) Blowing the nose
An older pt who is usually cheerful & cooperative demonstrates irritability & restlessness during morning hygiene. Which assessments would the nurse perform FIRST? a) Level of stress & ability to cope b) Changes in mental status & cognition c) Deviations from baseline mood & affect d) Feelings related to loss of independence
b) Changes in mental status & cognition
When a pt is admitted to the ED w/ DIC caused by sepsis, which prescribed action will the nurse take FIRST? a) Apply anti-embolism stockings b) Draw blood for culture & sensitivity c) Administer vancomycin 1 g IV d) Transfer the pt to the ICU
b) Draw blood for culture & sensitivity
The nurse assesses a pt who is experiencing profound (late) hypovolemic shock. When monitoring the pts ABG results, which response would the nurse expect? a) Hypokalemia b) Metabolic acidosis c) Respiratory alkalosis d) Decreased CO2 level
b) Metabolic acidosis
A pt has chest tubes attached to a chest tube drainage system. Which intervention would the nurse perform when caring for this pt? a) Clamp the chest tubes when suctioning b) Palpate the surrounding area for crepitus c) Change the dressing daily using aseptic technique d) Empty drainage chamber at end of shift
b) Palpate the surrounding area for crepitus
A pt is admitted to the PACU after a segmental resection of the right lower lobe of the lung. A chest tube drainage system is in place. When caring for this tube, what would the nurse do? a) Raise the drainage system to bed level & check patency b) Clamp the tube when moving the pt from the bed to a chair c) Mark the time & fluid level on the side of the drainage chamber d) Secure the chest catheter to the wound dressing w/ a sterile safety pin
c) Mark the time & fluid level on the side of the drainage chamber
The nurse is notified that the latest potassium for a pt who has an AKI is 6.2. Which action would the nurse take? a) Alert the cardiac arrest team b) Call lab to repeat the test c) Notify the HCP d) Obtain an anti-arrhythmic medication
c) Notify the HCP
Which action would the nurse take to determine patency of the chest tube & closed chest drainage system in a pt after a left lower lobectomy? a) Milk the chest tube toward the drainage unit b) check the amount of bubbling in the suction control chamber c) Observe for fluctuations of the fluid in the water-seal chamber d) Assess for extent of chest expansion in relation to breath sounds
c) Observe for fluctuations of the fluid in the water-seal chamber
After being notified that a pt w/ a sucking chest wound is being transported to the ED, the nurse will anticipate which INITIAL collaborative intervention? a) Obtaining a chest x-ray b) Notifying the on-call surgeon c) Preparing for chest tube insertion d) Drawing blood for labs
c) Preparing for chest tube insertion
A pt has a closed chest tube drainage system connected to suction. Which assessment finding requires additional evaluation by the nurse? a) A column of water 20 cm high in suction control chamber b) 75 mL of bright red blood in drainage collection chamber c) An intact occlusive dressing at insertion site d) Constant bubbling in the water-seal chamber
d) Constant bubbling in the water-seal chamber
Which nursing intervention is the PRIORITY for a pt in the acute-care setting w/ UOP: 250 mL in 24 hrs, blood osmolality: 310, systolic bp: 90? a) Consider it a normal finding b) Advise the pt to drink 2-3 L water daily c) Assess the BUN/ Cr levels d) Request an increase in IV fluid rate form the HCP
d) Request an increase in IV fluid rate form the HCP
Which statement reflects understanding of sepsis screening requirements by the nurse? a) Blood cultures are required to diagnose sepsis & begin sepsis protocol b) An oral temperature of 96.4*F (35.8*C) is not an indicator of sepsis c) A primary HCP prescription is required to screen for sepsis d) Sepsis mortality is affected greatly by treatments performed in the first 6 hrs
d) Sepsis mortality is affected greatly by treatments performed in the first 6 hrs
A pt is experiencing severeARDS. Which response would the nurse expect the pt to exhibit? a) Tremors b) Anasarca c) Bradypnea d) Tachycardia
d) Tachycardia
